VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Colonial Manor
8679 Pocahontas Trail
Williamsburg, VA 23185
(757) 476-6721

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: June 28, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Monitoring An on-site unannounced mandated monitoring conducted on 6/28/24 by two inspectors from the Peninsula Licensing Office. Ar (07:56 a.m./ Dep 13:50 p.m.). The facility census was 30. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 Number of staff records reviewed: 2 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 5 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-70-C
Description:	Based on staff interviewed, the facility failed to ensure that it submitted a written report of each incident to the regional licensing office within seven days from the date of the incident. The report shall be signed and dated by the administrator and include all required information. Evidence: 1. On 6-18-24, staff #1 reported by telephone an incident (death) of resident #4. The facility did not provide the licensing inspector with a written report within seven days. 2. On 6-28-24, staff #1 acknowledged not providing the licensing office with the required written incident report in accordance with the regulation and the facility?s policy and procedures reporting of incidents.
Plan of Correction:	To address the issue of delayed incident reporting, the facility will immediately update procedures to ensure all incidents, including deaths, are properly documented in our computer charting systems. This will streamline reporting incidents to the appropriated personnel responsible for creating and submitting the required written reports to the licensing office within seven days. Staff will receive additional training on utilizing the computer charting system for incident reporting to ensure accuracy and efficiency. Regular audits will be conducted to monitor compliance with these updated procedures.
Standard #:	22VAC40-73-450-E
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure the individualized services plan (ISP) was signed and dated by the licensee, administrator, or his designee, and by the resident or the legal representative. Evidence: 1. On 6-28-24, resident #1?s ISP dated 6-8-23 and 7-8-23 was not signed and dated by the resident?s legal representative. The record included the legal document dated March 29, 2023, noting the resident as an incapacitated adult and appointed a guardian. 2. Staff #1 acknowledged the resident?s legal representative did not sign the resident?s ISPs.
Plan of Correction:	To address the deficiency identified regarding the Individualized Service Plan (ISP) signatures, the facility will immediately implement corrective actions. We will review all current ISP documents to identify any instances where signatures from the resident's legal representative are missing. For those identified, we will promptly contact the legal representatives to obtain their signatures and ensure compliance with regulatory requirements. Moving forward, our procedures will be updated to include a systematic check during ISP creation and review processes to ensure that all necessary signatures---by the licensee, administrator, or designee, as well as by the resident or legal representative--are obtained and dated appropriately. Staff members involved in ISP development and management will receive additional training to reinforce the importance of obtaining and documenting these signatures accurately. Regular audits will be conducted to monitor adherence to the updated procedures and ensure ongoing compliance.
Standard #:	22VAC40-73-450-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure that the resident?s individualized service plan (ISP) included all assessed needs for a resident. Evidence: 1. On 6-28-24, resident #1?s physical examination dated 5-18-23 noted the resident has a pacemaker. This assessed need was not on the resident?s ISP dated 7-8-23. The resident?s uniformed assessment instrument (UAI) dated 7-18-23 noted the resident?s behavior as appropriate. The resident?s ISP dated 7-8-23 noted behavioral pattern need noted, ?when resident become agitated, care staff will attempt to redirect or re-approach at another time. Activities of interest will be held to limit resident?s agitation. Medication will be provided when necessary to calm resident down?. 2. Resident #2?s physician?s orders dated 5-1-24 and June 2024 medication administration record (MAR) noted the resident is allergic to Penicillin. The resident?s ISP dated 11-3-23 noted the resident has no allergy. 3. Staff #1 and #2 acknowledged the resident?s ISP did not include resident?s assessed need.
Plan of Correction:	To address the issues with residents' Individualized Service Plans (ISPs), we will take immediate action. We will review all current ISPs to find where medical conditions, allergies, and behavioral assessments are missing. After this review, we will update each resident's ISP to include all documented needs from their medical records, physician orders, and assessments. Staff involved in ISP development will receive training focused on accurately documenting and integrating medical information, allergies, and behavioral assessments into ISPs. We will establish a system to regularly check ISPs for accuracy and ensure they align with residents' records and assessments. Improved communication will help ensure timely updates and collaboration among healthcare providers, staff, and residents' legal representative. We will also conduct regular reviews and evaluations to make sure out ISP procedures are effective. Feedback from staff and residents' families will help us make improvements and provide better care for residents.
Standard #:	22VAC40-73-680-I
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure medication administration record included all requirements. Evidence: 1. On 6-28-24, resident #1?s June 2024 medication administration record (MAR) was observed with missing staff initials on 6-2-24; 6-8-24 and 6-15-24 for 8:00 p.m. for medications Abilify, Voltaren arthritis, Tramadol and Ensure; Synthroid on 6-8-24 and 6-12-24 (6:00 a.m.). 2. Resident #2?s June 2024 MAR missing staff initials on 6-2-24; 6-8-24 ad 6-15-24 for 8:00 p.m. medications Clonidine and Zyprexa; Ensure on 6-8-24 (8:00 p.m.). 3. Staff #1 and #2 acknowledged the residents? June 2024 MARs did not have the initial of staff on the dates noted as required.
Plan of Correction:	To address these deficiencies, immediate corrective actions will be implemented. Firstly, a comprehensive review of all current MARs will be conducted to identify instances where staff initials are missing. Subsequently, staff will be reminded of the importance of initialing each medication administration promptly and accurately at the required times. Staff will receive ongoing feedback and support to ensure consistent compliance with these procedures. Enhanced communication channels will also be utilized to reinforce expectations and facilitate timely updates to MARs as necessary.
Standard #:	22VAC40-73-870-E
Description:	Based on observation and staff interviewed, the facility failed to ensure all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition. Evidence: 1. On 6-28-24, during a tour of the facility with staff #2 and #3 the kitchen sink in a resident?s room (#27) was observed to have standing brown colored water and it also had an odor. 2. Staff #2 and #3 acknowledged the kitchen sink was not in good repair and condition.
Plan of Correction:	To address this issue, immediate corrective actions will be implemented. Firstly, the kitchen sink in Resident Room #27 will be inspected and repaired promptly to ensure it is in good working condition. Additionally, a thorough inspection of all furnishings, fixtures, and equipment throughout the facility will be conducted to identify any other items needing repair or maintenance. Staff will receive training on the importance of promptly reporting and addressing maintenance issues to ensure all areas of the facility are kept clean, functional, and safe for residents. Regular monitoring and audits will be established to verify compliance with maintenance standards and prevent recurring similar issues.
Standard #:	22VAC40-73-970-E
Description:	Based on documents reviewed and staff interviewed, the facility failed to ensure fire drills were conducted for each shift in a quarter and shall not be conducted in the same month. Evidence: 1. On 6-28-24, the fire drill documents noted fire drills conducted 1-22-24 (6 a.m.), 2-23-24 (3 p.m.), 4-17-24 (8 p.m.) and 6-12-24 (3 p.m.). 2. Staff #1 acknowledged the fire drills were not conducted as required.
Plan of Correction:	The fire drills mentioned in the documents were not conducted by the Fire Marshal as initially thought by Staff #1. Instead, these drills were organized and overseen by the facility's administration. The drills were announced using the fire alarm system as the form of notification to stimulate real-life emergency conditions. Staff #1's initial understanding about the Fire Marshal conducting the drills was incorrect. It appears there was confusion or misunderstanding regarding the nature of the drills and their scheduling. The drills were indeed conducted as part of our internal safety protocols to ensure staff readiness and resident safety in the event of a fire emergency. Moving forward, we will ensure clearer communication and understanding among staff regarding the origin and purpose of fire drills conducted by the facility versus those conducted by external authorities like the Fire Marshal. This will include providing additional training and clarification on the roles and responsibilities during fire drills to enhance to overall preparedness and compliance with regulatory requirements.